No. 4383

AUGUST 31, 1907.

THE LANCET.

LONDON: SATURDAY, AUGUST 31, 1907.

An Address to Students.IN the early days of October words of welcome and of

warning will be addressed in a certain number of medicalschools to the students entering upon the medical educationalcurriculum. The official introductory lecture is not now, asit was by former generations, considered to be an essentialfeature of the beginning of the winter session in everymedical school. Nevertheless, either in the old-established

manner, or through the pages of its hospital journal,or in the speeches at the inaugural dinner, or in someother formal or informal manner, each institution en-

Igaged in medical education endeavours to bring home toits new students the importance of the step they are takingin seeking entrance to the medical profession. These indi-

vidual sectional congratulations will necessarily to a largeextent be occupied in pointing out the advantages of the

particular university or medical school to which the fortu-nate student has attached himself, and in endeavouring tosow the seeds of the institutional esprit de corps which issuch an important element of medical as of all other formsof education.

A WORD OF WELCOME.

THE LANCET—and when we speak for ourselves we speakfor our readers-regards the annual festival of the induc-

tion of novices from a somewhat wider standpoint than thatnaturally taken by the introductory lecturer attached to

one of the seats of medical learning. The five or six proba-tionary years spent in what is technically regarded as theeducational period cannot be clearly defined from that longperiod of study which does not cease till the medical manretires altogether from the practice of his profession.Once a medical student always a medical student, andour congratulations are offered not so much to the

recruit as he enters upon his five years of more or less

irresponsible institutional life as to the budding pro-fessional man seeking the perpetual service of two hard

masters-science and the public. We most heartily and

unreservedly, then, congratulate all those men who havedecided on October lst, 1907, to put their hand to the

plough. There is only one class of man who must be

exempted from such congratulations-he who, looking roundfor an occupation in life in which to make money easily haschosen the medical profession : with him we must condole,for he has mistaken his path. To all others, whetherthey be attracted by a love of science, by the possession ofmechanical aptitude, by a desire for service to the afflicted, ormerely by a wish to follow in the footsteps of a father orsome other hero of their youth, our welcome is cordial andconfident. To all such an assurance may be given that hardas a medical man’s life may be in particular instances, in the

great majority of cases the good features undoubtedly pre-dominate over the evil. That there are a large number of

thoroughly unsatisfactory features in many branches of

practice none can doubt. Those who would minimise the

defects in the organisation of the medical profession whichprevent it from fulfilling its work with complete satis-

faction, either to the public or to its own members, woulddo an ill-service to the recruits about to enter its ranks.

To conceal these defects can only lead to disillusion whenthe student passes from the hospital to the full work of

his profession. To bring them before him in his early daysmay secure that he will be prepared to take his share in

minimising or removing them whenever opportunity arises.The existing defects, both in medical education and in thepractice of medicine, are of a class that is amenable to

treatment. They need deter none from joyfully and

hopefully entering our ranks. Whilst the founder of

THE LANCET was exposing in his vigorous manner the

glaring evils of the profession of his time there ap-

peared year by year in this journal an address of welcometo new students. To WAELEY, keen reformer as he was, wedoubt not that the existence of abuses to be battled with and

overthrown seemed an added attraction to those entering the

profession. We take a less combative line and do not set

forth the need of medical reform as a bait to intendingstudents, but we confidently ask the attention of all thosewho are joining us to some aspects in which the educationfor the practise of our profession falls short of the ideal,in order that being forewarned they may be forearmed, andso may secure for themselves and for their future patientsthe best that is possible under existing conditions.

THE VALUE OF MEDICAL TRAINING.

In urging each new colleague to try to escape the pit-falls that beset him during his official educational curriculumwe appeal direct to his self-interest. The avoidance of

evils that abound in his subsequent professional practice willlater require the exercise of a considerable amount of

altruism. It is fortunate, therefore, that the student’s lifein a medical school is well calculated to develop a truespirit of unselfishness. In fact, as a school of character it isdoubtful if any better could be devised than the routine

career of a medical student. It is not claimed that everymedical student at the end of his five years’ curriculumwill be found to have become a saint. But if he has not

developed manly qualities of self-restraint, courage, gentle-ness, and forbearance it is not for want of opportunityof practising these virtues. To every youth entering on his

probationary training for manhood there are opportunities,whatever calling he has chosen, of showing the stuff that heis made of and of putting into practice the precepts he haslearnt from his teachers, and especially from those candidfriends his school fellows. During the earlier period of amedical student’s career the conditions do not differ much

from those of all other boys on leaving their schools of

general education. The medical student’s temptations maybe rather greater in so far as supervision by authority overmedical students is in most instances less than in the case

of youths passing into office work in connexion with com-merce or other branches of activity. But it must be

remembered that many medical students are not youthsat all, while the interest of the work is incomparably

** I

572

greater than in most other oallings, and the risk of

leisure for which reasonable occupation is hard to find

need never be present to one who is entering upon thestudy of medicine. It is particularly in the second half ofthe hospital curriculum, when the student enters upon hisstrictly technical work, that he finds himself better placedthan his contemporaries in other walks of life for uncon-

sciously practising the higher virtues. Heaven forbid that we

should schedule these virtues or that a progressive universityshould include their exercise amongst the compulsorysubjects in an overloaded curriculum. It has been assumed

by some hysterical writers that the frequent contact withpain and suffering which is a necessary feature of hospitallife induces in medical students, and therefore in medical

men, hardness of heart and want of sympathy. That such

contact enables medical men to perform their necessary

professional service without the exhibition of emotion is, ofcourse, true, but that this implies the development of

inhumanity is false. The constant opportunity of social

service that a medical student can find in the wards and

out-patient departments of our great hospitals is the best

possible means of training his character for his future work.There is, perhaps, room for development in our hospitalsof cooperation with other agencies, medical and lay,engaged in dealing with social problems. The meaningof, and the possible remedy for, the life tragedies revealedin our hospital wards would thus be made clearer. There is

too much tendency, in London, at any rate, for each

hospital to regard itself as an independent factor in

dealing with disease. In the solution of the many socio-

logical problems that confront us the medical profession isdestined to take an important part, and there could be nobetter preparation for a medical man to carry out his shareof the work than in studying fully the social conditions ofthe patients that apply for treatment at the hospitals. But

the training would be still more effective if the student

were taught something of the way in which sanitary, poor-law, and other authorities cooperate with the hospitals andthe medical profession in the prevention as well as in thetreatment of poverty, crime, and disease.

THE LIMITATIONS OF THE MEDICAL CURRICULUM.From the intellectual and more strictly educational stand-

point the curriculum imposed upon medical students by theuniversities and licensing corporations has many defects.The curriculum is overcrowded, it is far too rigid, and aboveall it is seriously hampered by the requirements of the

examinational system. The medical student may as well

know these things on the threshold of his career. The

mere school-boy must accept without question the courseof study laid down by his masters ; no good comes from

raising doubts in his immature mind as to the advantagesof the modern methods of education. But just as libertyto work or play must gradually be given to the under’

graduate, so may the medical student, sometimes alreadya graduate, be invited to criticise the plans suggested

. for his education, and he should be allowed to some extentto choose for himself the methods best suited to hit

particular circumstances. Of course, he must pass hit

examinations, for only by passing examinations can h(

satisfy the State that he is fit to practise medicine. But

we would strongly urge all students now commencing thei)

studies to peruse the rfgulations put into their hands byauthority not as if they were inspired documents to beliterally obeyed but in a spirit of intelligent criticism.Let these regulations be recognised as attempts, byno means altogether successful, to meet the require-ments of the average man and to checkmate the idler,while holding the balance fairly as between the opposinginterests of universities, medical corporations and schools,and the State, and between the conflicting claims of

the advancement of the science of medicine and the

practical application of our art to the healing of disease.

Properly regarded in this light as a compromise betweenmany divergent views it is clear that official regulations canindicate an ideal course for very few individuals. Some

men learn best from systematic lectures, others from

personal intercourse with a demonstrator, others again from

practical laboratory work, and still others by the burningof midnight oil over the perusal of text-books or mono-

graphs. An official curriculum must provide for all these

methods of instruction, but the student himself and his mostintimate teacher can say alone in what proportion theyshould be combined in any individual case. It is only aftercareful perusal of the regulations and conferences with atrusted teacher that a student can learn how far he mayrisk a relaxation of regulations in one or other direction

in order that he may pursue to the full the course

of study which will best develop the powers of

his mind.

It is first essential that a medical student should have

clearly before him the fact that the sole object of

his five years’ course of study is not the passing of

his examinations. The passing of examinations is an

incidental necessity of medical education, but the successof any man’s course of study may be measured bythe extent to which he has been able to shake off the

fetters of the examination system. Harmful as is this

system to true education, a great deal of its disadvantagecould be avoided by a candid recognition by the student ofthe truly incidental character of an examination. He who

reads a book or attends a course of lectures on practicalwork with the object of answering the questions whicharise or have arisen in his own mind is making a properuse of the book or of the course of instruction. The

moment he consciously uses either book or lecture in

order to prepare himself to answer other people’s questionsthe spirit of cram has entered and the spirit of true

education suffers. To many students it may seem

that this differentiation between the proper and the im-

proper attitude towards their work is a subtle one and

hardly to be maintained. It is just because it is so

subtle that there is danger of its being overlooked.

It is, however, vital, and the student who learns

biology or chemistry not because he wants to know

the deeply interesting facts of these enchanting sciences

but because he wants to be able to answer the questions whichthe examiners at the preliminary scientific examination willask a few months later, starts his medical education in a

wrong spirit and bids fair to become one of the unhappy slaves sof the examination system. Fortunately, there is no excuse,

so far as the subjects of medical examinations themselves are, concerned, for approaching them in any spirit but that of the

573.

most insatiable inquisitiveness. If the medical student’s

desire to know has not been already hampered by schoolmethods he will have placed before him in crescendo scale

subjects of study which none but the most blaBé appetitecould regard with indifference. The only possible difficultyis that the second and third courses are so inviting thatthere is fear that the earlier fare may suffer by comparisonwith those that come after-may be bolted and not digested.

THE OVERCROWDING OF THE STUDENT’S TIME.

Medical students are sometimes consoled by their teachersfor the inevitable delay in reaching the study of diseaseand in coming into contact with patients by a considerationof the usefulness of their early studies in enabling themto understand the later. There would not be the same

necessity to plead utility if the prevalent system of exa-

minations would allow the teachers of the ancillary sciencesto present their subjects in their most interesting guiseunhampered by scheduled courses of instruction and

syllabuses for the guidance of external examiners. We

do not propose to discuss the possibility of altering thisstate of things at the present moment, for that would

be waste of time, but there is no reason why the studentshould not know what a ca.sua.1 perusal of recent proceedingat the meetings of the General Medical Council will reveal,that the medical curriculum is overcrowded and that the

percentage of failures in examinations is quite undulyhigh when the industry of the pupils and the zeal of

their teachers are taken into account. At the present time,while it is possible for an intelligent and industrious

student, aided by a thoughtful teacher, to escape some ofthe difficulties of a multitude of examinations in a too

rigid curriculum, it is not so easy to avoid the trouble.

due to the excessive number of subjects to ba dealt with

This overcrowding is especially noticeable in the latter partof his course, and is due to the fact that the State requiresevery medical man to be prepared to cope with a vastnumber of different emergencies. After he is qualifiedhe may, and almost must, decide to restrict his practice to

, certain branches of professional work, but at the outset heis expected to show at least an elementary acquaintancewith every professional department. It is only by the

exercise of method and industry in a very high degree that,

it is possible for a medical student to acquire this element

tary knowledge of all his subjects without running a riskthat his acquaintance with each is superficial as well as

elementary, while unfortunately the superficial acquaintancemay suffice for the purposes of an examination even more

aptly than deeper knowledge. It is essential that

from the very commencement of his studies a student

should work not only in the right spirit but with greatindustry and perseverance. He must look ahead and planout his leisure time as well as his working hours if he is topass his examinations in due sequence and also master the

ground-work of his professional studies.He must select forms of physical recreation which

can be fitted in with the exacting duties in the medicalschool and will yet be sufficient to maintain a highstandard of bodily health. Indifferent health will be

a serious bar to the practice of medicine, and may

prevent the satisfactory completion of the course of

study necessary in order to secure legal qualifications.

Physical exercise should be both a means of securinghealth and also of providing recreation and social inter-

course. If it can secure social intercourse with non-

medical students so much the better. Medical education is

very engrossing and there is a material risk that a student’soutlook may be narrowed despite, or because, of the plethoraof subjects with which he has to make himself more

or less familiar. He will need, when qualified, to

have the widest possible knowledge of mankind and

sympathy with the point of view of all classes. It is,therefore, well that a student, while not neglectingthe social, literary, and sporting clubs of his own

medical school, should take every opportunity of mixingwith students in all other faculties of his university ifhe fortunately belongs to one. It is the ease with which

such intercourse is obtained in the old universities that

makes Oxford and Cambridge so valuable as places in

which to pursue the earlier medical studies, while it is

one of the set-backs to the success of the University ofLondon that such intercourse is not yet systematicallypromoted. It should not, however, be impossible to securethe broadening influence of social intercourse in any

city in which medical education is carried on, and it will

be observed that all the provincial Scottish and Irish

universities are located in or in the vicinity of com-

paratively large cities. The moral of our words of

welcome and of warning, so far as the educational

curriculum is concerned, is that its splendid opportunitiesand results may well be missed by the man who lets

himself slide in the direction of least resistance, but will

certainly be secured in more or less full measure by anyonewho recognises the dangers and difficulties and sets out withthe fixed purpose of making the five years of medical studythe most profitable as well as the happiest years of his life.

THE PROFESSIONAL OUTLOOK.

It is an inevitable disadvantage of the disappearance ofthe old apprenticeship system from medical education thatonly a small proportion of our modem students when

first entering upon their work have a conception of what wemay call the ideals of the profession. In a former genera-tion the majority of general practitioners implanted in theirpupils the professional spirit without which the highestscientific training must certainly fail in producing the rightsort of medical practitioner. To-day this professional spiritmust be evolved by other means if the profession is to main-tain its noble traditions. If there is rather a loud outcry thatthese traditions are in special danger just now, we ventureto hope that this is due to the excessive introspectionand publicity of our time rather than to any real

lowering of the high aim of the majority of the profession.This high aim is distinctly an unselfish one and must be

kept constantly before each of us from the first momentof entrance into the ranks of medicine. It must be

encouraged on all hands by precept and by example. Some

believe that this high aim can even be compelled, to a

certain extent, by regulations imposed by professionalorganisation. But a nation cannot be made sober byAct of Parliament, nor can a profession be inspired with

lofty ideals by by-laws and codes of ethical rules. Yet

574

such codes have their value, and of those who

complain that to endeavour to govern the profession bycodes agree3 upon by the majority is to introduce the taintof trade unionism we would ask :-Can there be any

objection to a professional union bent on maintaining in eachof its units the highest traditions of an unselfish profession ?Should we not all rejoice to see a profession united in itsdetermination that every member shall do all in his powerfor the good of his patients and nothing that he can avoidthat might harm his colleagues ? It is such a spirit as thiswhich has always actuated and still inspires the majority ofthe medical profession. If there is some fear that keen-

ness of modern competition may lead to the intro-

duction of conduct based on the commercial mottoes

"caveat emptor" and "the devil take the hindmost,"there are also signs that the power of the majority to

prevent such conduct is steadily growing. We must teach

our students from the outset the great difference which

exists between our profession and a trade. He must

be trained whilst still at the hospital to look forward

to conducting his practice in accordance with the best

professional ideals and to participating in movements

for the strengthening of all the existing authorities withinwhose power it is to prevent backsliding in any branch of

our calling.THE SCIENTIFIC SPIRIT.

Whilst endeavouring thus to adopt the right professionaloutlook the student must also acquire the true scientific

spirit. Briefly this may be defined as the love of truth.

The temptation to accept dogma for truth and speculationfor demonstration is very great in medicine. The vast

advances which are constantly taking place in our sciencemake it above all things necessary that our students shouldacquire a capacity for judgment rather than a store of

so-called facts. The facts of one generation of practitioners,even of one generation of students, are many of them dis-carded by the next. A man who has acquired a trulyscientific spirit will be able to modify his point of

view to suit new theories and to adapt his practiceto the altered circumstances ; the change of front will

in his case mean a comprehension of the evolutionaryprinciples of science. He who has merely imbibed the

teaching of tradition will be without a guide when thefoundations of the tradition are seen to be not trulylaid. A medical man must love science for science’ sake,and he must desire knowledge for the added power thatit gives him to serve his fellow men. Whatever maybe the medical school of the student’s choice he will

surely come in daily contact with men devoting them-selves without stint to the search for truth. Whetherthe search be conducted in the laboratory or in the

wards he will find his senior colleagues devotingthemselves with equal zeal to the practical applicationof the truths of medical science to the relief of

suffering. Let these men be his heroes and let him

decide to carry out in practice the principles he will

learn at their feet. Thus will his five years medical

education be an education in the truest and highest senseand form a fitting prelude to the practice of a professionwhich with all its superficial faults remains one of the most

satisfactory of human occupations.

THE READING OF THE STUDENT.

IT has been our custom for very many years to make a,selection among the books dealing with the various subjects-of the medical student’s scientific and professional educa-tion, and this selection has been subdivided usually into twogreat categories-viz., books recommended for pass examina--tions and books recommended for honours examinations. Theselection of books was made with the cooperation of arepresentative group of professors, lecturers, and practicalteachers in the different medical schools, and was regularlyrevised from year to year. We believe that so far as it is,possible to pick out a library for the medical studentthat should be of practical use to him we accomplished’this task, but we have decided to attempt it no.

longer. The place of books in the medical curriculum hasbeen steadily altering, until the point is now reached thatthe only persons who can give valuable advice to medicalstudents as to what books they should buy are those whoactually superintend the instruction in the different subjects.The catalogues to be found in all recent issues of theStudents’ Number of THE LANCET enumerate books withinwhose covers there is contained more-much more-than itcan be conceivably necessary for any medical student toknow. We have nothing to add to and nothing to subtractfrom these catalogues. They do not comprise a very largelibrary for an earnest student to read in a curriculum extend-ing over five years, but if the books are read properly theywill amply suffice. Whatever care be devoted to the makingof a selective list the result will not be always perfectlysatisfactory for every student, for there is no work on anysubject which is suitable for all candidates and all examina-tions. Consequently when there are two books of equalstanding it may be impossible to say which is the betterof the two, and in such cases we have always giventhe reader a choice of alternatives. But however care-fully the attempt be made to choose books for the medical.student which may be useful to him in all the emergencies ofhis educational career, it is bound for the future to be only anattempt. The real work of the medical student is done nowin laboratories, in the dissecting room, in the wards, and inlaboratories again. Systematic reading, which will certainlyrender his negotiation of examination tests much more ready,must be done in accord primarily with his own ability to.,learn from books, and secondarily in response to the adviceof his many teachers.We may, however, usefully give a few general hints on.

the subject of reading by students. The student has to,remember that there are two objects which he should havein view : the first, which is usually looked upon as the more.urgent, is the passing of the various examinations which are-necessary for the degree or diploma he desires to obtain. Theother object is, however, of more importance ultimately, and"this is the attainment of a thorough knowledge of his pro-fession so that he may practise it to the benefit alike of his.patients and himself. The books which are most suitablefor the second object are not necessarily those which would,afford most assistance in attaining the first. The examina--tions must, alas, have the prominent place while he is yet a..student, for until he has surmounted these obstacles he isentirely precluded from the practice of his profession. In

choosing books for a particular examination the student must.avoid both reading too little and reading too much, and it Îfi.here that the advice of a teacher or a senior student shouldbe sought. For personal knowledge of the student isnecessary before he can be advised in the best way either as .to what he should read or as to how he should read it. Thegreatest danger lies, perhaps, in reading too widely. Manystudents dip into many books and fail to master any. _The student should recognise the scope of his ezamina--tions and should first endeavour to limit his reading tothe required standing. When, however, he has made-himself master of that portion of the subject which theregulations of the examination require he may go farther.A book might be very useful or even necessary forone examination and useless for another of a differentstandard, and if useless it is really harmful, for its perusalwill take up time which might be more usefully employed.The output of volumes from the medical press has increasedenormously ; but on the other hand, it is every year less andless important which particular work. ,the . student selects..,